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School-Related Medical Issues Archive 2010

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John L. Digges, MD, PhD, MPH, FAAP
(Fellow of the American Academy of Pediatrics)
Behavioral Pediatrician

Dr. Digges practiced general and behavioral pediatrics in Oklahoma and California for 14 years. For ten of the past 12 years, he has served as the Forensic (Child Abuse) Pediatrician for Kern County, California; and he has had a private practice limited to ADHD consultations for the past 12 years. He has been a CME surveyor for the Institute of Medical Quality (CMA) since 2000, and is a recent past-President of the Kern County Medical Society. Dr. Digges has been at the DCN since August, 2008.

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  • Is the dosage of Strattera too high for my son?

Question:

My 10 year old son weights 70 pounds and is being treated for ADHD using 2 mg. of Intuniv and 61 mg. of Strattera. Is this dosage of Strattera too high for him?


Answer:

Your son’s current dose results in a concentration that is above the FDA limit but below the limit which has been tested in controlled studies and found to be both effective and well tolerated. Allow me to explain.

Strattera is currently available in capsules of 10 milligrams (all white), 18 mg (gold & white), 25 mg (blue & white), 40 mg (all blue), 60 mg (blue & gold), 80 mg (brown & white) and 100 mg (all brown) strengths. [Although it is in capsule form, it is not recommended to “sprinkle” the contents to get in-between doses (i.e. 61 mg), as the medicine has an extremely bitter taste]. A 60 mg capsule taken daily by a 70 pound (31.8 kilograms) boy yields a concentration of 1.89 mg per kg of body weight per day.

The current FDA approved maximum dose for Strattera in children is 1.4 mg per kg of body weight per day. Studies have been conducted up to 2.0 mg per kg of body weight per day, showing efficacy and reporting no serious side effects. In two of the studies, the average dose taken was 1.6 mg per kg of body weight per day.

Physicians sometimes prescribe doses that are above the FDA approved dose, and this is considered to fall under “off label” prescribing. This is perfectly legal and is often quite reasonable, especially when there are data from previously conducted studies which demonstrate both efficacy and safety at the higher doses. I typically tell patients that we are exceeding the FDA approved dosing concentration (i. e. it is “off label”), but that there are data available showing that the medicine at that dose was effective and that the side effects were reported as similar to those experienced at lower doses.

Your son is on a relatively high dose for body weight, but whether it is “too high” will depend upon how he responds. If he displays unacceptable “side effects” on that dose, then I would say it is “too high” of a dose for him at his current weight. If his symptoms are significantly better on 60mg than on 50mg (2 capsules at 25 mg each, 1.67 mg per kg of body weight), or on 40 mg (1.26 mg per kg of body weight); and he does not experience any significant “side effects,” then I would say it is not “too high,” even though it is clearly “off label”.  (By the way, when your son weighs about 94 pounds, then a 60 mg dose would be equal to about 1.4 mg per kg of body weight.)

If you are uncomfortable about exceeding the FDA recommended limit, then you might wish to discuss other treatment options with your son’s physician.  An essentially on-label dose would be 46 mg (~1.4 mg per kg of body weight), which could be obtained by combining two 18 mg capsules with a 10 mg capsule.  However, I suspect this combination would be prohibitively expensive, so an alternative would be to give 40mg (1.26 mg per kg of body weight), and then titrate a second medication until symptoms become manageable and side effects are acceptable. The choice of medication would depend upon your son’s specific situation, and should be discussed with your son’s physician.

I hope this is helpful to you. Thank you for your question.

John L. Digges, MD, PhD, MPH, FAAP


  • Is 18 mg of Concerta sufficient for my 9 year old?

The question below was sent to our assistive technology specialist who felt that it might be better addressed by an education specialist and our physician. Our combined response follows.

Question:

Dear Dr. Digges,

My son started taking Concerta and was on 18 mg for about 10 days. He tolerated it well, so the doctor increased to 36 mg. He has now started complaining of headaches and an upset stomach. He is 9 years old and weighs 71 pounds. I did notice a positive change when he was on 18 mgs, but the doctor advised me this is just a dosage to see if the child will tolerate the medicine. Do you know what percentage of children in his age/weight range are on 18 mg and find it to be effective? Could it be that 18 mg is and will be sufficient until he gets a little older? As of today I will decrease the dosage back to 18mg, as having a headache and stomach ache are not acceptable, especially when he is in school and trying to get work done. 

Thank you,
Carol Lawson


Answer:

Dear Carol,

Thank you for your question. Side effects such as headaches and abdominal pain are sometimes seen when a child’s dose of stimulant medication is being titrated upwards. Such symptoms are often dose related, but may resolve spontaneously over a period of 2-3 weeks. If the headaches and abdominal pain do not go away after 2-3 weeks, then I recommend consultation with your physician and  consideration of a trial of 27mg Concerta each morning. If the headaches and abdominal pain recur on 27mg and do not resolve after 2-3 weeks, then I would return to 18mg.  Although this low dose is typically insufficient to reduce symptoms significantly, I have seen 18mg of Concerta produce adequate symptom reduction on several occasions; including cases involving children with autistic spectrum disorders or with AD/HD predominantly inattentive type. If 18mg of Concerta gives the best balance between symptom reduction and adverse events, then it would be fine to continue on that dose.

Stimulant dose is typically related to the severity of the symptoms and also to the rate at which the child metabolizes the medication, rather than to the child’s weight. Age is somewhat involved, in that metabolic rate may decrease after puberty. Increases in dosage are nevertheless occasionally required as children get older, and there may be a number of different reasons to consider increasing a child’s medication dose.

When doses are kept in the therapeutic range (18-54mg is FDA approved for a 9 year old), it would be exceedingly rare for a child to develop true tolerance to the stimulant medication. Rather, I suspect that something else has occurred. In some cases, the original dose may have resulted in significant improvement, but may not actually have been the child’s optimal dose. As your child gets older and the academic demands increase, it may be necessary to increase the dose in order to function optimally.

AD/HD often occurs together with one or more other conditions such as an anxiety disorder, depression, a learning disability or a speech and language disorder. Once the AD/HD symptoms are reduced, it is generally easier to tell what other conditions may remain which interfere with the son’s academic success. These other factors can often be treated more effectively once the AD/HD symptoms have been reduced. After the co-existing condition has been addressed, there may be no need to increase the dose of AD/HD medication.

Some  children need to be reassessed for the possibility that environmental variables have produced significant stress for the child, and have decreased their child’s ability to remain focused on school work. Reduction of the degree of threat the child perceives will reduce the stress and may allow a return to their previous level of academic performance without necessarily having to increase the medication dose.

Additionally, a child who has been doing well on a particular dose for years and then starts doing poorly may be suffering from a chronic sleep disturbance. This could involve the quantity of sleep, the quality of sleep, or both. A thorough evaluation of this possibility with the child’s pediatrician would be appropriate in such situations.

For any child beginning treatment with stimulant medications, it is important that the dose gradually be titrated upwards until there is significant to complete symptom resolution without any unacceptable side effects. It is often helpful to identify three or four areas in which your child is struggling, and then follow his response to the medication with respect to each of the identified domains. If significant improvement in the areas being monitored happens to occur at the lowest dose, so much the better for you and your son. I hope this has been helpful, and I wish you and your son well.

John L. Digges, MD, PhD, MPH, FAAP


  • Acute asthma, ADHD, and dyslexia.

The question below was sent to our assistive technology specialist who felt that it might be better addressed by an education specialist and our physician. Our combined response follows.

Question:

I have a 16 year-old child who is in special education at a local high school here in northern California.  He has been diagnosed with acute asthma, ADHD, and dyslexia by a neuropsychologist.  This school year he has missed approximately three weeks of class time due to asthma attacks and complications therein.  Subsequently, our child is left to attempt to make up such assignments as Algebra II assignments on his own. 

Well, as I am sure you are aware, this is not going very well, and his RSP instructors are constantly complaining to me and are suggesting that I further discipline my child.  We all know that those with dyslexia try everything possible to avoid reading and math.  However, I am unable to convince the school district to provide our child with proper FAPE with regards to dyslexia intervention.  Though our child’s RSP instructors have no problem continuously complaining about our child being behind in assignments missed due to asthma attacks.

What do you suggest is the proper educational interventions for a child whose medical condition is affecting his education?

Thanks,
Pete


Answer:

Dear Pete;

Asthma is typically an inherited condition with environmental triggers. Recognizing and reducing the triggers is critical. Since the condition involves both bronchospasm and inflammation, treatment will generally include medications from both classes (bronchodilators for “rescue” such as albuterol, and anti-inflammatory medications for maintenance treatment such as an inhaled steroid). There are also medications (leucotriene inhibitors like Accolate and Singulair) which can help reduce the susceptibility of the airways to asthma attacks, and can be viewed as being a form of preventive treatment.

Poorly controlled asthma can also result in disturbances in the quantity and quality of sleep. An insufficient amount of deep sleep (stage 4) and REM (rapid eye movement) sleep can result in feeling tired upon awaking, being more susceptible to infections, and increased irritability. These symptoms can exacerbate AD/HD symptoms and can contribute to your son’s being unavailable for learning during the school day.

It is especially important that your son understand this medical condition and the effects it may have on his daily life.  He should be meeting with his doctor to fully understand symptoms and symptom management.  You also might contact the local chapter of the American Lung Association, as they often have classes on understanding and coping with asthma. This will not only help to increase his self awareness but self-advocacy skills; skills needed to independently navigate the “adult” world. 

My colleague, Shari Gent, has suggested strategies for homework and class work completion in her Ask A Specialist section, ADHD.

We hope these strategies will help your son reduce the frequency and duration of his symptoms related to asthma, as one important goal of treatment is to eliminate or at least minimize school absences due to this condition.


  • Advice on helping school teams when they are talking to parents of children that have ADHD about considering treatment options with their pediatrician?

Question:

Hi Dr. Digges,

I attended a Diagnostic Center workshop yesterday with Diann Grimm.  She said you have very good information about ADD/ADHD for educators.  I have a question for you:  Do you have any advice on helping school teams when they are talking to parents of children that have ADHD about considering treatment options with their pediatrician? Or children that have lots of symptoms of ADHD that are not diagnosed actually making an appointment to have a candid discussion about the issue?  I find that there are some children that have a lot of behavioral strategies and supports in the classroom but still struggle tremendously with ADHD symptoms and parents who are extremely defensive with us when we try to discuss the issue of discussing the above two scenarios with their child’s pediatrician.  We see the children really struggling—it’s not about the adults not wanting to deal with the children.   On the flip side we see children who make great improvements when under the care and guidance of a physician combined with the school supports.

Thank you!

Kimberly Factor


Answer:

Hi Kimberly,

Let’s start with how not to respond. I have had several parents tell me that “the school” informed them that their child could not return to class unless he/she were on medication. That’s obviously a no-no. A “one size fits all” approach is likewise inappropriate (“Your child needs to be on X medication.”)

The approach you alluded to is much more defensible. Start with your observation that their child appears to be struggling, or is not making much progress academically despite making what appears to be their best effort. Ask the parents if they have noticed the same thing, and if they have any ideas about what to do with respect to their child’s dilemma. Their response to your concern will provide guidance to you about which approach is most likely to result in a favorable outcome.

If they ask for suggestions, you could inform them that several children in your classes have responded well following a thorough medical evaluation and appropriate treatment. You could suggest that they start with the child’s regular pediatrician, who will be in the best position to either perform the evaluation and manage the treatment themselves, or refer the child to an appropriate specialist.

The management of AD/HD can be challenging, and it is critical to locate a physician who is both knowledgeable about and experienced with the diagnosis and treatment of AD/HD in children. I like to spend considerable time educating the family and the child about the condition and the importance of various treatment modalities. Typically, I will start all AD/HD children on non-pharmacologic strategies first, and reassess how they responded after 3-4 weeks of intensive effort. If the symptoms have been reduced and performance has significantly improved, then I may elect to follow them over time. If their best efforts have not resulted in adequate improvement, however, then we can begin the discussion about considering medication as an option. There are currently “lots of tools in the toolbox” when it comes to medications for AD/HD. A thorough evaluation of the child’s symptoms, demands, compensatory skills, and co-morbid conditions will influence the recommendation concerning which combination of molecule and delivery mechanism will most likely be the best fit for a particular patient.

It is also important to realize that the non-pharmacologic strategies need to be continued even after a medication is introduced. With the help of medication, many children will be able to follow through on their intentions to a much greater degree than they could without medication. This will allow them to be more successful in earning rewards for their efforts (The child should be functioning under the positive reinforcement paradigm that the parents have been taught to use in place of the previously used and ineffective negative reinforcement paradigm).

All children need to undergo a transition from external control of their behavior to self-regulation of their behavior as they enter into late adolescence and adulthood. Children with AD/HD typically take longer and require more external supports to successfully complete this journey. The nature of the “executive function” deficit in AD/HD results in the child having to struggle to inhibit certain behaviors which non AD/HD children can inhibit with minimal effort. The AD/HD child is most likely to thrive when external supports are in place to help compensate for the child’s inability to access internal controls. The judicious use of medication can provide the child with more consistent access to internal controls over their behavior, and allow them to benefit from the improved executive function capability of their brain.

Thank you for your question, and I hope this response is helpful.

John L. Digges, MD, PhD, MPH, FAAP


  • Do you feel 27mg is too much for a ten year boy who weighs 70 lbs?

Question:

My son who is 9 soon to be 10 years old was diagnosed with ADHD in August of 2009 by a child psychiatrist at CHOP. Prior to his diagnosis we had him in behavioral therapy for over 1 year with no real improvement.  I remember as early as preschool his teachers always made comments like, "his head is in the clouds." He wasn't a behavior problem in his early years but has since developed some significant behavior issues and was also diagnosed with ODD.  

After many years of not medicating and trying every other alternative, we began giving him Strattera 25mg in August.  He’s had no real side effects but still continued with impulsive behaviors and struggled somewhat with attention and focus.   At his check up the pediatrician suggested Intuniv to help with both disorders. We began 1mg and continued to increase to 2mg after 1 week.  This medication was not right for him.  He was all over the place in school and lost all focus and attention.  After following up with his pediatrician and discussing other options he suggested a stimulant (CONCERTA).  We began 18mg of Concerta over spring break and noticed no significant change (however he was not in school so homework was not an issue). We did have him do some studying and writing and he was very dependent on myself and  my husband for too much help.  Anyhow, his teacher is stating he had his worse day ever with impulsiveness, lack of focus and concentration.  He has been on Concerta for 10 days @18mg and I spoke at length with his pediatrician and a Pharmacist but I still feel like I need some answers.

In your professional opinion, do feel as though 27mg on Concerta will take effect if 18mg does not? Also, do you feel 27mg is too much for a ten year boy who weighs 70 lbs?

Thank you so much for your time. 

Michelle Nagy


Answer:

Dear Michelle,

Thank you for your question, as it touches upon several important issues. It sounds like your son has problems with both his academic performance and his behavior. Has the teacher been collecting data to support her statement?

Please keep in mind that my answer is one of a general nature and should not be construed as medical advice. Your son’s pediatrician should be closely following his medications.

Children with AD/HD are often “boredom averse,” in that they appear to be motivated to do almost anything rather than be bored (e.g. they may embrace risk taking behavior). This is believed to result from underperfusion of their frontal lobes and prefrontal cortex when they are bored. This deficiency in oxygen and nutrients can also be associated with an unpleasant or “dysphoric” feeling state.

One way of looking at why children with AD/HD behave the way they do is that they search out different stimuli until they find something that elicits an emotional response in them. This response is thought to produce an increase in perfusion of blood to their frontal lobes and prefrontal cortex, which in turn causes their dysphoric feelings to subside. Their choice of behaviors may be inappropriate to their setting, and cause disruption in the class or at home. Even though the behavior may be viewed as adaptive from the perspective of reducing their dysphoria, it is maladaptive from the perspective of the people around the AD/HD child.

The people who are negatively impacted by the AD/HD child’s behavior often exhibit their displeasure at the behaviors; which they typically perceive as disruptive, willfully non-compliant, disrespectful and inappropriate. The AD/HD child may lack insight into the connection between their behaviors and the response of people around them, and may perceive that they are being unfairly singled out for reprimand and punishment. The AD/HD child may begin to see the world as capricious or even hostile, and they may consequently adopt behaviors which they believe to be an appropriate response to their perceived mistreatment, but which others identify as “oppositional” and “defiant.” There appears to be a “two-way miscommunication” occurring, and part of the treatment involves explaining this phenomenon to all of the players.

The role of medication in AD/HD is to try to normalize what is believed to be an abnormal brain biochemistry in the regions of the brain which control “executive function.” Atomoxetine or Strattera is a selective norepinephrine reuptake inhibitor, and causes the concentration of the neurotransmitter norepinephrine to increase. This action is believed to allow the neurotransmitter level in the synaptic cleft to increase to the degree that the nerve impulse is transmitted appropriately from one neuron to the adjacent neuron (instead of being blocked as a result of insufficient neurotransmitter availability in the space between the adjacent neurons). The dose of Strattera is usually titrated upwards slowly from a low starting dose to a level around 1.2-1.6 mg/kg. A child who weighs 70 pounds would be expected to respond optimally at about 40 mg/day (about 1.3 mg/kg/day), although that dose could range from 25mg (about 0.8 mg/kg) to 50 mg (1.57 mg/kg/day). The optimal efficacy of Strattera may take weeks to months to occur, so patience is a virtue. Unlike the situation with stimulant medications, the dose of Strattera is based upon the weight of the child, so will need to be increased gradually as the child grows.

Intuniv, which has recently been approved by the FDA for the treatment of AD/HD, is a long acting form of the medication guanfacine (the short acting form of guanfacine has the trade name Tenex). It seems to help most with symptoms of aggression, but appears to provide little help with the attention issues that your child has.

Concerta is a timed release preparation employing methylphenidate (the medication in Ritalin) and the OROS release mechanism. Methylphenidate is a stimulant which appears to primarily inhibit the reuptake of the neurotransmitter dopamine, thereby producing a higher concentration of dopamine in the space between the adjacent neurons. This combination of a medium potency stimulant with a sophisticated release mechanism results in a pharmacokinetic curve which has both a sustained upslope and a sustained downslope. The upslope portion of the curve provides optimal help with cognitive improvement in AD/HD children, while the plateau (maximal) portion of the curve corresponds with reduction in non-goal directed motor activity excess. The gentle downslope portion helps to minimize the “withdrawal” side effects (increase in emotional lability) often seen with higher doses of short acting methylphenidate preparations (those having a steeper downslope portion of the curve).

Working closely with your pediatrician is critical. Beginning treatment with 18 mg of Concerta is prudent, as a slow titration upwards in dose appears to help the body adjust to the effect of the medicine and results in decreased instances of headache and abdominal pain. It would be unusual, however, for 18 mg of Concerta to be the optimal dose for a 70 pound boy with the symptoms you describe. Under your pediatrician’s care, it may be perfectly fine to titrate the dose upwards gradually, watching for a decrease in AD/HD core symptoms on the one hand, and an absence of unacceptable side effects on the other. Some side effects are unavoidable with medications, so it is important that your physician review common side effects with you, and discuss ways of managing most of the common side effects.

Concerta comes in strengths of 18mg, 27mg, 36mg and 54 mg. A 45 mg dose can be achieved by combining an 18mg tablet with a 27mg given together in the morning, but this may result in two co-pays and is more expensive. Remember, with stimulants your pediatrician will titrate the dose based on symptom reduction and side effects, not on your child’s weight.

Also, effective treatment of the core AD/HD symptoms often results in the child experiencing both increased success and a decrease in the behaviors which irritated the people around them. This combination of effects often results in the child no longer needing to resort to the “aggressive,” “oppositional,” and “defiant” behaviors which led to the ODD (oppositional defiant disorder) diagnosis.

Thank you again for your question and I hope this response is helpful to you and your son.

John L. Digges, MD, PhD, MPH, FAAP


  • As a mandated reporter, am I obligated to report this as sexual abuse?

Question:

I teach 6 th grade, and one of the girls in my class told me that she has been having sex with her “boyfriend,” who is an 8 th grader. As a mandated reporter, am I obligated to report this as sexual abuse? If so, how long do I have to make the report and to whom should I report?

Perplexed, Oakland


Answer:

Dear Perplexed:

The first step in a situation such as you describe would be to notify your principal and to comply with the policies and procedures of your school district. In addition, your school administrator may want to investigate this situation further and/or involve other school staff such as the school nurse or counselor.

According to California statute, whether you need to report “consensual” sexual activity as “suspected sexual abuse” (“exploitation”) for the most part depends upon the ages of the individuals involved. In your situation, if the “6 th grade” girl is 11, 12, or 13 years old and the “8 th grade” boy is 14 years or older, then you are mandated to report. If however, the “8 th grade” boy is 12 or 13 years old and the “6 th grade” girl is 11, 12, or 13 years old, you are not mandated to report. Consensual sex between two individuals age 14 years or older does not require a report, unless the younger person is 14 or 15 years old and the older person is 21 years of age or older.

Reporting suspected abuse (sexual, physical, or neglect) is mandated for teachers; when they have “reasonable suspicion” that abuse has occurred. “Reasonable suspicion” is interpreted to mean that the information presented to you causes you to suspect that the child has been abused or neglected. Reasonable suspicion may result from a disclosure, observation of concerning physical findings, or changes in behavior. The mandated reporter is not obligated to prove that abuse or neglect has occurred, and is not responsible for ascertaining the validity of a particular disclosure.

The report should be made to law enforcement or child protective services (or both) by telephone “immediately” or as soon as is practical. Law enforcement would be your first choice in situations where the child appears to be in immediate danger. A written Suspected Child Abuse Report (SCAR Form 8572) needs to be submitted within 36 hours of the time of the disclosure to you. The identity of the mandated reporter is made known only to the investigating agencies, the attorneys involved with any related legal proceedings, and the licensing agency in the case where the abuse or neglect is suspected to have occurred in an out of home care setting. The mandated reporter is also granted both civil and criminal immunity from prosecution (unless the report is a false report known to be false at the time the report was made).

I hope this is helpful.

John L. Digges, MD, PhD, MPH, FAAP


  • Do we need to ban peanuts from our school?

Question:

Dear AAS Medical,

We have a child in our middle school reported to have a “severe” allergy to peanuts. We are struggling with some very passionate and vocal competing interests in trying to determine an appropriate response. How significant is the problem, and do we need to ban peanuts from our school?

Theresa Stallings


Answer:

How significant is the problem?

A child who is reported to have a “severe” allergy to peanuts may very well have demonstrated a serious or life threatening reaction to peanut exposure in the past. For such a student, exposure to even a tiny amount of peanut or peanut product can be fatal. Not all children who have a “peanut allergy” will have a serious reaction when they are exposed to peanuts. However, even though a child with a “peanut allergy” has never had a serious reaction, it is possible that the child’s next exposure could result in a serious, and even fatal, response.

Fatal reactions to peanut exposure in an allergic individual can result from either of two different mechanisms. First, they can experience nearly instantaneous constriction of their airway (laryngospasm), which can block the passage of air. If airflow is not established within a few minutes, the person will asphyxiate and die. Second, the individual can have an anaphylactic reaction to the allergen, where immunoglobulin E (IgE) mediates a massive immune response. If not reversed, this cascade of reactions can result in collapse of the cardiovascular system and can cause death in anywhere from several minutes to 1-2 hours. There are estimated to be about 100-150 deaths each year attributed to “peanut allergies,” but I was not able to find out exactly how many of those deaths occurred in school-aged or middle-school aged children.

Do we need to ban peanuts from our school?

Although many schools have made the decision to ban peanuts from their school, declaring a school to be “peanut-free” is not a panacea. The primary benefit of a ban is that it raises the awareness of the potential for inadvertent harm to a child who is at risk, and hopefully motivates parents and students to do what they can to protect each severely allergic child from harm. However, no declared ban can guarantee that there won’t be accidental exposures to peanut in some minute amount, which could nevertheless be catastrophic for a particularly allergic child. A “peanut ban” has the potential to create a false sense of security, and could result in allergic individuals being less vigilant about avoiding potential exposures to peanut, or in the school not being prepared to respond immediately in case of laryngospasm or anaphylaxis. At the present time, it is crucial for children with a life-threatening allergy to peanuts and their families to be always on the alert to avoid even minute peanut exposures.

Family members, selected school staff and, when appropriate the child, should all be knowledgeable about the indications for and the administration of epinephrine (e.g. an EpiPen injector). As a matter of fact, the California Education Code 49414 states: (a) A school district or county office of education may provide emergency epinephrine auto-injectors to trained personnel, and trained personnel may utilize those epinephrine auto-injectors to provide emergency medical aid to persons suffering from an anaphylactic reaction.

One promising development which could fundamentally reduce the risk of serious allergic reactions to peanut exposure involves systematic oral desensitization. Peanut allergic individuals are given tiny doses (e.g. equivalent to 1/1000 of a peanut initially), and then have their exposures gradually titrated upwards. This has resulted in children being able to tolerate several peanuts without having an allergic reaction. Although not intended to allow peanut allergic individuals to be able to consume large quantities of peanut, the process does seem to eliminate the potential for accidental minute exposures to produce a significant allergic reaction. The procedure requires medical supervision, and is NOTappropriate for families to try at home!

A second possibility for relief could come in the form of medications which block the immunoglobulin E response to allergens. Trials are currently underway, but there is at least some early indication that these medicines do reduce the potential for an allergic individual to experience a serious reaction to an exposure involving a tiny amount of peanut.

Within a few years, it may be possible to prevent severe allergic reactions to peanut in the vast majority of children. In the meantime, peanut free schools, peanut free lunch rooms, and peanut free lunch tables are among the strategies which have been adopted by various schools in their attempts to balance the potential life-threatening consequences for the small minority of students who have a severe allergy to peanuts, against the inconvenience of the vast majority of non-peanut allergic students who are not able to bring peanut products to school.

School board policies concerning anaphylaxis in general and severe peanut allergy in particular, generally address a) increasing awareness, b) maximizing avoidance of allergen, and c) preparing to respond to a medical emergency. At a minimum, I would recommend that every school that has even one peanut allergic student, faculty or staff member:

  1. provide comprehensive education directed towards all students, staff and parents about the seriousness of inadvertent peanut exposure for a highly peanut-allergic individual; discourage all parents and staff from sending peanut products in any form to school; and discourage peanut allergic individuals from sharing foods
  2. develop a treatment plan agreed to by parents and school officials that also includes emergency contact information
  3. be prepared to respond immediately and appropriately should a peanut allergic individual have a severe reaction after having been exposed to peanut (i.e., provide necessary medical training for classroom staff.)

John L Digges, MD, PhD, MPH, FAAP 
Behavioral Pediatrician, Diagnostic Center for Northern California


  • Help with communication to parents as well as finding the right combination of strategies to help this child.

Question:

Dear Shari and John:

My question is regarding a second grade student in an elementary school LD class of thirteen students who has been diagnosed with severe ADHD. His parents do not believe in medication, partially for cultural reasons. I normally do not advocate for medication unless it is necessary, but feel this child has great potential. He is extremely verbal and intelligent. Consequently, his disruption to the class is an ongoing distraction. This behavior is affecting his progress as well as the progress of each student in the class. A reward system for good behavior, tied to computer use which he enjoys has been implemented, but it is not enough. Any help you could give with communication to parents as well as finding the right combination of strategies to help this child would be greatly appreciated.

Thank you for your time and expertise.

Sue Kitson


Answer:

Dear Sue:

What a great question! We have collaborated to answer your question from our respective areas of expertise; Shari, a special education educator and John, a behavioral pediatrician. We have generated our response the concerns you expressed in your question:

  • Communicating with your second grade student’s parents
  • Developing strategies to optimize his learning.

MEDICATION ISSUES:

It would be helpful to identify the basis of the parents’ rejection of medication for a chronic medical condition. Some parents have the view that medications are used to “control” their child’s behavior, and that the medication will “change who he is.” Another perspective is that medications help to restore a normal balance to a biochemical system which has become out of balance. Once that existing imbalance is corrected, then the child will have new options with respect to their behavior and the choices they make. The options chosen by the child can be affected by a variety of non-medication interventions, including the parenting approaches used and making the best use of positive reinforcement to obtain desired choices and behaviors.

It might be helpful for you to encourage the parents to meet with a physician experienced in diagnosing and treating AD/HD, who could explain to the parents:

  • The neurobiological basis of AD/HD, especially its impact on the “executive function” aspect of the brain,
  • How changes in brain function can affect behavior in ways that are not under the control of the child,
  • That adults often assume that the behaviors of an AD/HD child are entirely volitional and indicate willful non-compliance which should be punished,
  • That the child with AD/HD may perceive the world around them as unfair and at times hostile, and may adopt behaviors to help them deal with that perception,
  • How medications can help to normalize the biochemistry in parts of the brain where it may be abnormal,
  • That an increase in neurotransmitter concentration in the tiny space between neurons can allow communication between neurons to improve, and thereby lead to improvements in both brain functioning and in performance,
  • What potential side effects can occur and how to manage them effectively,
  • That AD/HD patients off medication are about three times more likely than AD/HD patients on medication to develop substance abuse disorders,
  • That there are now multiple medication options available, so that the specific needs of the child can be used to guide the physician’s choice of which medication is most likely to result in maximum improvement with acceptable side effects for that child,
  • That the dose and even the choice of medication will often be changed as a result of the child’s response to a medication trial, and
  • That the medications can always be discontinued if deemed necessary.

Parents typically want “the best” for their children. Helping these parents to enter into a therapeutic relationship with a physician who is both knowledgeable about and experienced in the diagnosis and treatment of AD/HD in children may help the parents to redefine what is “the best” treatment for their child.

BEHAVIORAL STRATEGIES:

Regarding behavioral strategies, we often assume that children with AD/HD should respond to these in the same way as typical peers. However, research has demonstrated that, because of their unique neurological make-up, children with AD/HD respond differently than typical peers. Behaviors consist of a sequence of three events, often referred to as the “ABC’s” of behavior: the antecedent, or events preceding the behavior; the behavior itself; and the consequences produced or affected by the behavior. Students engage in behaviors, both appropriate and maladaptive, as a way to communicate needs and produce specific results or consequences- generally to “get” or “reject” objects, activities, or situations. Consequences provide feedback about the appropriateness or correctness of a response, social attention, and stimulation.

Dr. Sydney Zentall suggests that because of an internally driven need for stimulation, students with AD/HD find positive and negative stimulation alike to be reinforcing. Many forms of emotional arousal have the effect of normalizing the under perfusion of oxygen and nutrients to the frontal lobe regions of the brain (which is characteristic of the AD/HD child’s brain when he is bored). Yelling, for example, will tend to increase the probability that inappropriate behavior in the child with AD/HD will increase because:

  • yelling produces conflict and its accompanying emotions,
  • the emotional response results in increased perfusion of blood to the frontal lobe areas,
  • this results in a decrease in dysphoric feelings, and
  • satisfies the AD/HD child’s need for intense stimulation.

For students with AD/HD, positive consequences or rewards must immediately follow the behavior and be more intense and frequent than those for typical peers. In addition, children with AD/HD tend to become bored with specific rewards as soon as the stimulus is no longer novel. If your behavior plan provides time on the computer as an activity reinforcer, consider if the reward is being offered frequently enough. Also ask if your student might be bored with that particular activity. Try varying the reward frequently – for example, change the software or website activity, or change the actual activity reward. Try providing the reward at shorter intervals, such as offering time on the computer for short intervals multiple times during the day.

Immediate Rewards:

In addition, research has demonstrated that when students with AD/HD are offered a choice of delayed or immediate rewards, they choose to complete fewer problems for a smaller reward given more immediately. Typical classmates tended to choose to complete more problems for a bigger, but more delayed reward. When all rewards were given immediately, the children with AD/HD worked more problems for the larger rewards just like their peers. So, when thinking about immediacy, you may have the option to offer a shorter computer time or an activity such as taking a short walk that may not be as rewarding as the computer time that you are currently offering. However, the reward may need to be given at shorter intervals.

Positive Praise:

Shower your student with frequent positive praise. Studies indicate that five positive statements to every corrective statement is generally optimal. Students with AD/HD respond best when their effort is recognized promptly, rather than waiting for them to achieve a desired goal. When you see your student focused and working, even for a few minutes, compliment him. Use intense praise that provides specific feedback about what your student is currently doing – for example, “You are really working like gangbusters on that math!”

Response Cost Strategy:

Finally, you might want to consider a modified “response cost” strategy, shown to be a powerful intervention for many children with AD/HD. We all experience response cost in our daily life - we must pay a fine when we have a traffic violation, pay fees for overdrawing our checking account, and in football, infractions result in yardage penalties. These can be powerful deterrents. However, emotionally fragile children can become upset when reinforcers are taken back. Children with AD/HD may react explosively when punished with fines or deductions of points or tokens already earned. In the modified cost response strategy, termed “free cost response” by school psychologist Dr. Terry Illes, removal of a token serves as a warning rather than a punishment.

To implement free cost response, start by taking a baseline of how often the target behavior occurs in a given period of time. Baseline data is essential for this strategy because it sets the bar for success. Start by targeting one observable behavior such as poking other students. Teach your student a replacement behavior such as holding a fidget or whispering to a partner. Then follow these basic steps:

  1. Determine the number of tokens to be given to the child initially.
  2. Determine the length of time the child’s behavior will be monitored. Plan to start with a short period of time and gradually lengthen the time as the child improves.
  3. Introduce the program. Remove one token for each occurrence of inappropriate behavior.
  4. At the end of the session, if at least one token remains, provide the reinforcement.
  5. As the child’s behavior improves, the sessions can be lengthened or the number of tokens can be decreased.

This sample monitoring card for kindergarten students was designed by a local kindergarten teacher.

Each large square represents one ten minute activity. By taking data during a formal observation, this teacher determined that her student poked others about three times on average in a ten minute period. She decided that it was realistic for the student to restrain touching others to twice during each short work period. If the student inappropriately touched another student, one happy face was crossed off. At the end of the ten minute period, if one happy face remained, the student received her reward, in this case a scented sticker.

We hope this explanation is useful in modifying behavioral support for your student, and wish you success in your efforts on behalf of this child. For additional information, consult these resources:

Shari Gent, MA Education Specialist

John L. Digges, MD, PhD, FAAP Behavioral Pediatrician

RESOURCES:

MEDICAL:

National Resource Center on AD/HD

  • Website: http://www.help4adhd.org/
    This invaluable resource includes comprehensive and reliable information about all aspects of AD/HD. The website also includes a series of printable pamphlets entitled “What We Know” (WWK) about all aspects of AD/HD. Links to the latest news about AD/HD are available.

American Academy of Pediatrics

The American Academy of Child and Adolescent Psychiatry

  • Website: http://www.aacap.org/
  • Pamphlet: “Facts for Families” available in English, Spanish, Deutsch, Malaysian, Polish, Icelandic, Arabic, Urdu and Hebrew and includes information on AD/HD and on psychiatric medications in general.

BEHAVIORAL:

  • Book: CHADD Educator’s Manualby Chris Dendy, CHADD (2006) *The chapter “Advanced Strategies for Challenging Behaviors” by Illes, T. & Weiss, S will be particularly helpful. Available at http://www.chadd.org
  • Book: ADHD and Education by Sydney Zentall, Upper Saddle River, NJ: Pearson Education, Inc. (2006)